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Share this Story: Palliative care in a pandemic: 'Patients who are not expected to survive should not be abandoned'

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Local palliative care providers are racing to overcome logistical hurdles — acquiring personal protective equipment, training staff, co-ordinating resources — in order to provide end-of-life care to those people expected to die at home during the COVID-19 pandemic.

Ottawa’s residential hospices are not accepting COVID-19 patients, but palliative care is available to people who decide against hospital treatment and want to die at home, said Nadine Valk, executive director of the Champlain Hospice Palliative Care program.

Palliative care in a pandemic: 'Patients who are not expected to survive should not be abandoned'Back to video

The size and speed of the pandemic is a challenge, she said, and planning for the end-of-life needs of patients in the region is moving ahead on several fronts.

“It means what could be offered to someone in the home today, honestly, might look very, very different three days from now,” she said in an interview Tuesday.

Palliative care often involves co-ordinated visits by home care workers, nurses, family physicians or palliative care specialists. In the past, those health care workers have rarely used personal protective equipment (PPE), but the pandemic makes it a necessity. The problem is that PPE is in short supply, and other homecare and hospital workers are also desperately searching for more protective equipment.

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“This is on a so much bigger scale than anyone has seen before,” Valk said.

In an interview Tuesday, Dr. James Downar, head of the division of palliative care at the University of Ottawa, called palliative care a human right for all dying patients. He said it must be maintained — even in the face of a humanitarian crisis.

“The current COVID-19 pandemic will likely strain our palliative care services,” said Dr. Downar, a palliative care physician at The Ottawa Hospital and Bruyère Continuing Care. “But we’re not doing our job if we’re not preparing for the possibility that we’re going to see here what has been seen elsewhere — in places like Italy.”

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Even in wealthy countries hit by COVID-19, the authors noted, the demand for ventilators and intensive care has outstripped supply. “No sustainable system of health care can hope to accommodate such a surge in demand,” they said. “But those who are denied access to critical care have a right to expect high-quality palliative care in place of a ventilator.”

Among other things, they recommend that hospitals stockpile pain medication, expand the number of staff members able to deliver palliative care, and introduce systems to guarantee that all patients receive end-of-life care. “Failing to deliver palliative care in this context,” they said, “would compound the tragedy of the pandemic and would arguably be a more substantial failure of the health care system.”

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At The Ottawa Hospital, Downar said, doctors and nurses have been “empowered” by the palliative care team to offer quality end-of-life care. There are also plans, he said, to create a unit dedicated to the palliative care of COVID-19 patients if the need arises.

“I think we have a very good system in place,” he said.

In Ottawa, hospices are not an option for dying COVID-19 patients. Lisa Sullivan, executive director of Hospice Care Ottawa, said the organization has been forced to halt its community programs — many involve older volunteers — and restrict hospice beds to people who do not have COVID-19.

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Hospice Care Ottawa operates the May Court and Ruddy-Shenkman hospices, which have a total of 21 beds for dying patients.

“At this point in time,” Sullivan said, “we are not on a priority list to have personal protective equipment so we have limited supplies and, because of that, we are not accepting any COVID-positive or suspected patients.”

Most critical COVID-19 patients will also not be able to take advantage of medical assistance in dying (MAiD) since it requires time-consuming legal steps.

It’s for that reason that Dr. Downar and his colleagues recommend the use of “palliative sedation” for those COVID-19 patients whose symptoms are not relieved by commonly-used medications. Sedatives can be used to reduce a patient’s level of consciousness so that they don’t suffer as they fight to breathe.

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The authors said palliative sedation is preferable to MAiD since medical assistance in dying requires a 10-day reflection period, two medical assessments and the consent of a patient with full capacity. “Attempting to honour an urgent MAiD request is likely to prolong suffering in those who are imminently dying,” they said.

COVID-19 patients who require palliative care, they said, will likely include older adults who do not want to be put on a ventilator; others who have been removed from a ventilator because their conditions have not improved; and a third group denied ventilation because of a “triage approach” in which only those with the best opportunity of surviving are afforded intensive care. Some patients with other serious health problems, comorbidities, could be denied a ventilator under a triage system.

The authors concluded: “Any triage system that does not integrate palliative care principles is unethical. Patients who are not expected to survive should not be abandoned but must receive palliative care as a human right.”

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